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RS Medical Information/Emergency Authorization
RS Registration - Medical information and medical care
STUDENT MEDICAL INFORMATION
Student Name
Date of Birth
Student's doctor and phone number
List any known allergies, as well as severity and treatment method.
List any physical or other limitations your child has, and any special procedures to be followed in caring for your child.
Does your child have any special needs that might affect the learning experience in Religious School (e.g. cognitive impairments, learning disabilities, emotional/behavioral issues, sensory impairments, medical needs)?
Yes (please explain below)
No
Special needs explanation referred to above.
List any medications student is currently taking, including dosage and frequency.
Describe any special dietary restrictions.
To the best of my knowledge, the above-named student is in good physical and mental condition and capable of active participation in all activities except for the following:
Legal Guardian Name
Date
MM slash DD slash YYYY
AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I hereby give my permission to Congregation Ner Tamid's Religious School and the agents, officers, and servants thereof to choose and secure emergency medical treatment and for chosen doctor, hospital, or medical service to provide emergency medical care and/or surgery for my child name above. It is understood that every effort will be made to locate the parents/guardian, or one of the emergency contacts listed on this form before any treatment is sought. I agree to cover any expense incurred by such treatment.
Legal Guardian Name
Date
MM slash DD slash YYYY
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